Kusserow on Compliance: Countdown to mandated nursing facility compliance programs

– Only months remain to evidence having an effective compliance program

– Many have a lot to do before state agencies begin their assessments

– Nursing homes lag behind hospitals in compliance program development

Tom Herrmann, J.D., served over 20 years in the OIG’s Office of Counsel and for the past ten years has been a compliance consultant, specializing in nursing home compliance programs. He explained that the Affordable Care Act included a mandate that skilled nursing facilities and nursing homes adopt and implement an effective compliance and ethics program as a condition of participation in the Medicare and Medicaid programs with a November 28, 2018 deadline established in regulations issued by CMS. At that time, State survey agencies will begin assessing nursing facility development and implementation of an effective compliance and ethics program, as a condition for participation in the Medicare and Medicaid programs. Reviews will be conducted under the CMS State Operation Manual “Guidance to Surveyors for Long Term Care Facilities”.  The new mandate parallels the HHS OIG Compliance Program Guidance for Nursing Facilities with its identified seven elements of an effective compliance program. Those that followed the OIG guidance will have little problem in meeting the new mandate, but those who did not, have only months to come into compliance. Based on his experience, he believes that facilities have a lot to do to come into compliance before state agencies begin their assessments, as many have delayed or limited resources for compliance program development.   He suggests that the most cost effective method to begin catching up to have a compliance expert perform a gap analysis to identify elements needed for the compliance program and how be able to evidence program effectiveness. A gap analysis should provide a “road map” and step-by-step plan for bringing a facility into compliance with the mandates. Those that have already implemented their compliance program should consider having an effectiveness evaluation conducted to experts that follow the review protocols that will be used by government auditors.

For more information about meeting the standards of these new mandates, Tom Herrmann may be reached at thermmann@strategicm.com or at (703) 535-1410.


Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2018 Strategic Management Services, LLC. Published with permission.